Methods and instruments for interbody surgical techniques

ABSTRACT

This invention relates to methods and instruments for performing a surgical procedure in a disc space between adjacent vertebrae. The instruments include a distractor and a cutting instrument. In one embodiment the distractor includes a body portion and a pair of flanges extending along opposite sides of the body portion such that a slot is formed between the flanges and the body portion. The cutting instrument is positionable over the body portion and into the slots of the distractor so that the flanges are positioned between the cutting instrument and the adjacent tissue.

CROSS-REFERENCE TO RELATED APPLICATION

This application is a continuation of U.S. patent application Ser. No.09/692,980, filed Oct. 20, 2000, and issuing as U.S. Pat. No. 6,599,291which is hereby incorporated by reference in its entirety.

FIELD OF THE INVENTION

The present invention relates to spinal surgical techniques andinstruments. More particularly, while aspects of the present inventionmay have other applications, the invention provides instruments andtechniques suited for interbody spinal surgery.

BACKGROUND OF THE INVENTION

Normally, intervertebral discs, which are located between endplates ofadjacent vertebrae, stabilize the spine and distribute forces betweenthe vertebrae and cushion vertebral bodies. The discs may be displacedor damaged due to trauma, disease or aging. A herniated or rupturedannulus fibrosis may result in nerve damage, pain, numbness, muscleweakness, and even paralysis. Furthermore, as a result of the normalaging processes, discs dehydrate and harden, thereby reducing the discspace height and producing instability of the spine and decreasedmobility. Most typically surgical correction of a disc space includes adiscectomy (surgical removal of a portion or the entire intervertebraldisc.) The discectomy is often followed by preparation of the vertebralendplates to receive an implant, such as a fusion device. Fusion of theadjacent vertebrae is used to alleviate the pain associated withabnormal joint mechanics, premature development of arthritis, and damageto the spinal structures.

Traditional surgical procedures for correction of spinal defects cancause significant trauma to the nerves and vasculature adjacent thespine. The potential for tissue trauma can be of particular concern whenthe surgical procedure dictates the use of a cutting instrument in thedisc space in order to remove disc and bone material to prepare the discspace for a fusion device, intervertebral spacer, or other implant. Inorder to minimize the potential trauma, surgical procedures can requiredenervation and devascularization of tissue adjacent the disc space.Other procedures require manipulation of the nerves and vasculature inorder to provide clear access to the disc space. While reducing thepotential for contact with surgical instruments, manipulation andremoval of the nerves and vasculature can still result in trauma and anincrease the time and difficulty of the surgical procedure.

U.S. Pat. No. 5,722,977 to Wilhelmy, incorporated herein by reference inits entirety, discloses a method and instrumentation for removal of apair of rectangular blocks of vertebral bone tissue to provide anintervertebral recess. The instrumentation includes an intervertebralmortising cutter and a spacer that acts as a guide for the cutter. Theprocedure first requires the spacer to be inserted between the vertebralbodies. The cutter has a cutting head that defines a cavity thatreceives the spacer. In order to remove the bony material, the cuttinghead is pushed around the spacer and into the disc space. Onedisadvantage with the instrumentation disclosed in the '977 patent isthat the cutting head is positioned between the spacer and the adjacentnerves and vasculature.

U.S. Pat. No. 5,484,437 to Michelson discloses a technique andassociated instrumentation for inserting a fusion device from aposterior surgical approach that provides protection for the surroundingtissues and neurological structures during the procedure. As describedin more detail in the '437 patent, the surgical technique involves theuse of a distractor having a penetrating portion that urges thevertebral bodies apart to facilitate the introduction of the necessarysurgical instrumentation. The '437 patent also discloses a hollow sleevehaving teeth at one end that are driven into the vertebrae adjacent thedisc space created by the distractor. These teeth engage the vertebra tomaintain the disc space height during subsequent steps of the procedurefollowing removal of the distractor. In accordance with one aspect ofthe '437 patent, a drill is passed through the hollow sleeve to removeportions of the disc material and vertebral bone to produce a preparedbore for insertion of the fusion device. One disadvantage with thistechnique is that the procedure is performed through a sleeve, thuslimiting working space and visibility of the surgeon. A furtherdisadvantage is that the height of the prepared disc space is limited bythe spacing between penetrating portions of the distractor and the innerdiameter of the sleeve.

While the more recent techniques and instrumentation represent anadvance over earlier surgical procedures for the preparation of the discspace for insertion of implants between the vertebrae, the need forimprovement still remains. The present invention is directed to thisneed for improvement and provides convenient methods and instruments forsafe and effective spinal surgical procedures.

SUMMARY OF THE INVENTION

The present invention is directed to a spinal disc space distractorhaving a pair of flanges that protect adjacent tissue from a cuttinginstrument. The present invention is also directed to a spinalinstrument assembly for distracting and cutting a disc space to preparethe disc space for insertion of one or more implants therein. Thepresent invention is further directed to surgical methods and proceduresusing the distractor and spinal instrument assembly.

In accordance with one aspect of the invention, a distractor isprovided. The distractor includes a body portion extending between aleading end and a trailing end. The body portion has an upper surfaceand an opposite lower surface, and opposite first and second sidewallsextending between the upper and lower surfaces. A first flange and asecond flange extend from the leading end of the body portion towardsits trailing end. The first and second flanges are spaced a distancefrom a respective one of the first and second sidewalls.

In accordance with a further aspect of the invention, a distractor isprovided that includes a body portion extending between a leading endand a trailing end. The body portion has an upper surface and anopposite lower surface, and opposite first and second sidewallsextending between the upper and lower surfaces. The body portionincludes a cavity formed therein that extends between the upper andlower surfaces.

In accordance with another aspect of the invention, a spinal instrumentassembly for distracting and cutting the disc space between adjacentvertebrae is provided. The assembly includes a distractor and a cutter.The distractor includes a body portion extending between a leading endand a trailing end. The body portion includes opposite first and secondsidewalls extending between the adjacent vertebral bodies. Thedistractor also includes a first flange and a second flange extendingfrom the leading end towards the trailing end of the body portion. Eachof the first and second flanges forms a slot along the body portion witha respective one of the first and second sidewalls. An elongated stemextends proximally from the trailing end of the body portion. The cutterincludes a cutting head at the distal end of a shaft. An upper member, alower member, and a pair of sidewalls extending therebetween form theshaft and cutting head. A channel extends through the cutting head andshaft. The channel is sized to receive the stem of distractor and toreceive the body portion of the distractor such that the distal end ofthe sidewalls of the cutter are positionable in the slot and the bodyportion of the distractor is received in the channel.

According to a further aspect of the invention, a distractor is providedwith an interfitting cutter having a channel sized to receive thedistractor. The cutter has width that is less than the width of thedistractor.

According to another aspect of the invention, a method for preparing adisc space between adjacent vertebrae is provided. The method includes:accessing the disc space through the skin and tissue of a patient;inserting a distractor into the disc space, the distractor having a bodyportion extending between a leading end and a trailing end, thedistractor further including a first flange and a second flangeextending from the leading end towards the trailing end of the bodyportion, each of the first and second flanges forming a slot along thebody portion; and positioning a cutting head over the body portion andinto the slots.

Further embodiments, forms, aspects, objects, features, benefits andadvantages of the present invention shall become apparent from thedetailed drawings and descriptions provided herein.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a top plan view of a distractor assembly according to oneaspect of the present invention.

FIG. 2 is an enlarged top plan view of the distal end portion of thedistractor assembly of FIG. 1 and the distal end portion of a cutter.

FIG. 3 is a side elevational view of the distal end portion of thedistractor and cutter of FIG. 2.

FIG. 4 is a perspective view of a distractor-cutter assembly accordingto a further aspect of the present invention.

FIGS. 4( a) and 4(b) are sectional views taken through lines 4(a)–4(a)and 4(b)–4(b), respectively, of FIG. 4.

FIG. 5 is the perspective view of the distractor-cutter assembly of FIG.4 with a handle attached the proximal end of the cutter.

FIG. 6 is a cross-sectional view of an alternate embodiment distractoraccording to the present invention.

FIG. 7 is a cross-sectional view of another alternate embodimentdistractor according to the present invention.

FIG. 8 is a top plan view of the distractor assembly of FIG. 1 with thedistractor inserted into a disc space from a generally posteriorapproach.

FIG. 9 is a top plan view of the distractor-cutter assembly of FIG. 5with the distractor in the disc space and the cutter adjacent the discspace.

FIG. 10 is the distractor-cutter assembly of FIG. 5 with the distractorand the cutter in the disc space.

FIG. 11 is an enlarged view of the distal end portion of the distractorand cutter in the disc space.

FIG. 12 is an enlarged top plan view of the distal end portion ofanother embodiment distractor and cutter according to the presentinvention.

FIG. 13 is a side elevational view of the distal end portion of thecutter of FIG. 12.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

For the purposes of promoting an understanding of the principles of thepresent invention, reference will now be made to the embodimentsillustrated in the drawings, and specific language will be used todescribe the same. It will nevertheless be understood that no limitationof the scope of the invention is intended thereby. Any alterations andfurther modification in the described processes, systems, or devices,and any further applications of the principles of the invention asdescribed herein are contemplated as would normally occur to one skilledin the art to which the invention relates.

The instruments and methods of the present invention have application toa wide range of surgical procedures, and particularly spinal proceduresfor preparing a disc space for insertion of an implant into the discspace. It is further contemplated that the surgical instruments andmethods of the present invention have application in open surgicalprocedures and in minimally invasive surgical procedures.

Referring now to FIG. 1, a distractor assembly 10 insertable into thedisc space between adjacent upper and lower vertebrae is provided.Distractor assembly 10 includes a handle 12 connected to a proximal endof a stem 16 via handle coupling 14. A distractor 18 is secured to adistal end of stem 16. It is contemplated that distractor 18 can bepermanently affixed or removably attached to stem 16.

Referring now further to FIG. 2, distractor 18 includes a body portion20 extending between leading end 22 and trailing end 24. Distractor 18has a pair of opposite outermost sidewalls that are formed by a firstflange 26 and a second flange 28 secured to body portion 20 at leadingend 22. Flanges 26, 28 extend from leading end 22 towards trailing end24. It is preferred that flanges 26, 28 are integrally formed with bodyportion 20 at leading end 22. In the illustrated embodiment, a first endwall 46 extends between leading end 22 and first flange 26 and a secondend wall 48 extends between leading end 22 and second flange 28.However, flanges 26, 28 could also be removably attached to body portion20.

Body portion 20 has first sidewall 30 and an opposite second sidewall32. As shown in FIG. 3, each of the sidewalls 30, 32 extend towards theadjacent vertebrae between an upper surface 34 and a lower surface 36 ofbody portion 20. Referring back to FIG. 2, a first slot 42 is formedbetween first flange 26 and first sidewall 30. A second slot 44 isformed between second flange 28 and second sidewall 32. Slots 42 and 44have a width “d” sized to accommodate the distal end of a cuttinginstrument 52, as discussed further below.

Body portion 20 further includes a cavity 38 formed therethroughextending between upper surface 34 and lower surface 36. Body portion 20has a height H1 between upper surface 34 and lower surface 36 thatcorresponds to the desired height for the distracted disc space. In theillustrated embodiment, the leading end portion of body portion 20tapers to a reduced height H2 between upper surface 34 and lower surface36 at leading end 22 to facilitate insertion of distractor 18 into thedisc space. Preferably, flanges 26, 28 have a height that is equal to oris less than height H1 of body portion 20, and have a tapered portionthat corresponds to the taper of body portion 20 towards leading end 22.The depth of insertion of distractor 18 into the disc space can bemonitored under direct vision, with a viewing element inserted in thedisc space, or via x-ray or fluoroscopic imaging of distractor 18.

Referring to FIGS. 2–5, according to a further aspect of the invention acutting instrument or cutter 52 is provided that cooperates with and isinterfittable with distractor 18 to form a spinal instrument assembly50. Spinal instrument assembly 50 provides for distraction of theadjacent vertebrae and for cutting material from the disc space and/orthe adjacent vertebrae to form an implant insertion location. Cutter 52includes a shaft 64 and a cutting head 53 at the distal end of shaft 64.Shaft 64 includes a first sidewall 58 and an opposite sidewall 60.Sidewalls 58 and 60 are connected by an upper member 54 and an oppositelower member 56. Upper member 54 includes an upper cutting edge 54 a atits distal end and lower member 56 includes a lower cutting edge 56 a atits distal end. While the illustrated embodiment has shaft 64 with asquare cross-sectional shape, other shapes are also contemplated,including, for example, a circular or rectangular cross-section.

Shaft 64 includes an interior channel 62 formed therethrough that opensat the distal end of cutter 52. As shown in FIG. 4( a), channel 62 has adistal first portion 62 a sized to receive stem 16 and body portion 20of distractor assembly 10 with handle 12 removed from stem 16.Preferably, first portion 62 a has a size slightly larger than bodyportion 20 and a shape approximating the shape of body portion 20. Thisprovides a slip fit between body portion 20 and cutting head 53 thatwill guide cutting head 53 into the disc space and into the bonymaterial of the adjacent vertebral bodies. Although the cross-section ofthe remaining proximal portion of channel 62 can have any shape, it iscontemplated that the entire length of channel 62 has a shape thatcorresponds to the shape of first portion 62 a.

Distractor 18 has an overall width W1 between the first flange 26 andsecond flange 28 that is greater the width W2 between the sidewalls 58,60 of cutter 52. Distractor 18 thus ensures that when distractor 18 andcutter 52 are interfitted the flanges or outer-most sidewalls ofdistractor 18 are positioned adjacent the neural and vasculature tissuerather than the cutting edges of cutter 52.

In an alternate form shown in FIG. 4( b), channel 62 can be providedwith a proximal second portion 62 b that has a size slightly larger thanstem 16 and a cross-sectional shape that approximates the outer surfaceof stem 16. This minimizes the relative movement between stem 16 andcutter 52 as cutter 52 is slidingly advanced along stem 16.

In one alternate embodiment shown in FIG. 6, distractor 18′ has a bodyportion 20′ with a circular cross-sectional shape defined by firstsidewall 30′, opposite second sidewall 32′, upper surface 34′ and lowersurface 36′. First flange 26′ and second flange 28′ each have a curvedshape that parallels body portion 20′, although vertically orientedflanges could also be provided. First slot 42′ is formed between firstflange 26′ and sidewall 30′ and second slot 44′ is formed between secondflange 28′ and sidewall 32′. In this embodiment, a cutter would beprovided with a circular opening at its distal end and a cross-sectionalshape that allows rotation, either manually or other known power means,about body portion 20′ to cut the adjacent vertebral endplates. Flanges26′ and 28′ protect the adjacent tissue from the rotating cutting head.Alternatively, a non-rotating cutter could be used with distractor 18′.

In another alternate embodiment shown in FIG. 7, distractor 18″ has afirst upper groove 21″ formed between upper surface 34″ and sidewall 30″and a second upper groove 23″ formed between upper surface 34″ andsidewall 32″. Distractor 18″ further has a first lower groove 25″ formedbetween lower surface 36″ and sidewall 30″ and a second lower groove 27″formed between lower surface 36″ and sidewall 32″. The channel of cutter52 can be configured to interfit with these grooves, thus allowing thegrooves to guide the cutting edges of the cutter into the disc space.First slot 42″ is formed between first flange 26″ and sidewall 30″, andsecond slot 44″ is formed between second flange 28″ and sidewall 32″.Grooves 21″, 23″ 25″, and 27″ resist upward and downward movement of thecutting blades with respect to distractor 18″ while flanges 26″ and 28″protect the adjacent tissue from the cutting blade.

Referring back to FIGS. 2–5, upper member 54 includes an opening 68 andlower member 56 includes an opening 70 (FIG. 4( a)) identical to opening68. These openings are substantially alignable with cavity 38 ofdistractor 18, and facilitate the removal of cut material from cavity 38when the instrument assembly is withdrawn from the disc space aftercutting bony material. Cutter sidewall 60 includes a recess 72 formedtherein, and cutter sidewall 58 includes a similarly shaped recess (notshown.) The recesses allow cutting edges 54 a and 56 a to be advancedbeyond the leading end 22 of distractor 18. End walls 46, 48 preventcutting head 53 from being advanced too far beyond leading end 22 ofbody portion 20.

Sidewall 60 includes a window 80 to further provide visual observationand/or confirmation of the position of cutting head 53 with respect todistractor 18 by enabling viewing of depth markings on stem 16 ofdistractor assembly 10. Shaft 64 further includes an imaging probe 74adjacent its proximal end to provide image-guided control and monitoringof cutter 52. Further details regarding probe 74 are provided in U.S.Pat. No. 6,021,343 to Foley et al., which is incorporated herein byreference in its entirety. Also contemplated are the use of x-ray andfluoroscopic imaging techniques to visualize cutting head 53 as it isinserted in the disc space.

Shaft 64 has a height H3 at its distal end that corresponds to thedesired height of the prepared disc space into which the implant is tobe inserted. It is contemplated that cutter 52 is inserted into the discspace with upper member 54 and lower member 56 parallel to the vertebralend plates and guided by body portion 20 of distractor 18. It is furthercontemplated that a number of cutters 52 of increasing height H3 may beprovided and sequentially inserted over distractor 18 for removal ofbony material from the vertebral endplates. While the illustrated cutter52 has flat cutting edges 54 a, 56 a, other shapes for the cutting edgesare also contemplated. For example, rounded upper and lower cuttingedges could be used to cut an arched path in the vertebral endplates. Astandard coupling 76 is provided at the proximal end of cutter 52 forattachment to a cutter handle 78 to facilitate gripping and control ofcutter 52. The proximal end of cutter 52 can also be connected to orcontacted by a driving tool, such as a slap hammer or the like to drivethe cutting edges 54 a, 56 a into the bony material.

The steps of the spinal surgical procedure in accordance with one aspectof the present invention are depicted in FIGS. 8–11. In the depictedsteps, there is illustrated a disc space D between adjacent vertebralbodies having a posterior side P and an anterior side A. The skin andtissue are excised and disc space D is accessed using any known surgicaltechnique and instruments. Typically, an opening is made in the discannulus at the desired entry location, and all or part of the discnucleus can be excised through this annulus opening. As shown in FIG. 8,distractor 18 of distractor assembly 10 is inserted into disc space D todistract disc space to the desired height between the adjacentvertebrae. It is contemplated that, if necessary, the disc space can besequentially distracted by known distractor instruments before insertionof distractor 18 or sequentially distracted by a number of distractors18 of increasing height H1 until the desired disc space height isobtained.

When the desired distraction has been achieved, handle 12 is thenremoved from the proximal end of stem 16 and, as shown in FIG. 9, cutter52 is slid over the proximal end of stem 16 to position cutting head 53adjacent the disc space and distractor 18. As shown in FIGS. 10 and 11,cutter 52 is advanced over body portion 20 of distractor 18 so that thebony material of the vertebral endplates is cut by cutting edges 54 aand 56 a. At least a portion of the cut material is deposited in cavity38 of distractor 18. Cutter 52 forms a path or track for implantinsertion while distractor 18 maintains disc space distraction. Flanges26, 28 protect the adjacent vasculature and nerves, such as dura S andnerve root N, as cutter 52 is advanced over and interfitted with bodyportion 20.

When the implant insertion path is cut to the desired depth into thevertebral endplates, distractor assembly 10 and cutter 52 can be removedfrom disc space D. The material in cavity 38 can be removed throughopenings 68, 70 of cutter 52 to facilitate disassembly of theinstruments. Further cleaning and debris removal in disc space D can becompleted if necessary before one or more implants are inserted into thedisc space. The inserted implant may be any device suitable forinsertion into the disc space. In one specific form, it is contemplatedthat an implant is inserted in the disc space in order to restore thedisc height, restore segmental alignment and balance, and immobilize theunstable degenerated intervertebral disc area. The implant(s) may beconveniently implanted with any known instruments and tools, and anyinstrument that will firmly hold the implant and permit insertion in thedisc space is contemplated. In one specific form, the implant is afusion device such as a bone dowel, push-in implant, threaded implant orthe like, that is advanced into the site prepared with the instrumentsof the present invention at the subject disc space. The inserted implantprovides support of the adjacent vertebrae, and can be packed with bonegrowth material to facilitate fusion. Graft material may also be placeddirectly in the prepared bore in the disc space, either without anyimplant or packed around the inserted implant.

It is also contemplated that more than one implant can be inserted atbi-lateral locations in the disc space through either a single lateralor transforaminal approach to the disc space, or through multipleapproaches taken with an anterior or posterior mid-line approach to thedisc space. The inserted implants provide bilateral support of theadjacent vertebrae, and can be packed with bone growth material tofacilitate fusion.

The instruments and methods have been disclosed with reference to aparticular application for disc space preparation and implant insertionfrom an oblique, posterior approach to the spine. However, it will beunderstood that the instruments and methods may be utilized, or modifiedfor use, for a variety of surgical applications and approachesincluding, but not limited to, a unilateral posterior approach, alateral approach, other oblique approaches, and an anterior approach.The instruments also have applications with laparoscopic or endoscopicprocedures on the spine, such as, through the working channelcannula/endoscope decribed in U.S. patent application No. applicationSer. No. 09/160,882 filed Sep. 15, 1998, which is incorporated herein byreference in its entirety.

Referring now further to FIGS. 12–13, an alternate embodiment spinalinstrument assembly having a cutter guided by a distractor will bedescribed. Assembly 150 includes a distractor 118 having a body portion120 extending between leading end 122 and trailing end 124. Body 120 isattached to stem 116 at trailing end 124. Distractor 118 has a pair ofopposite outermost sidewalls 126, 128 formed by body portion 120. In oneform, a slot 142 extends from position adjacent leading end 122proximally through body portion 120 and stem 116. Slot 142 preferablyextends substantially along the longitudinal center axis of distractor118. An end wall 146 is formed between leading end 122 and slot 142.

Body portion 120 further includes a cavity 138 formed therethroughextending between the upper and lower surfaces of body portion 120. Bodyportion has a height between the upper and lower surface thatcorresponds to the desired height for the distracted disc space. Theleading end portion of body portion 120 can be tapered as discussedabove with respect to distractor 18.

A cutting instrument or cutter 152 is provided that cooperates andinterfits with distractor 118 to form spinal instrument assembly 150.Cutter 152 includes a shaft 164 and a cutting head 153 at the distal endof shaft 164. Shaft 164 includes a first sidewall 158 and an oppositesidewall 160. Sidewalls 158 and 160 are connected by an upper member 154and an opposite lower member 156. Upper member 154 includes an uppercutting edge 154 a at its distal end and lower member 156 includes alower cutting edge 156 a at its distal end. Upper member 154 includes anopening 168 and lower member 156 includes an opening (not shown) thatare substantially alignable with cavity 138 of distractor 118, andfacilitate the removal of cut material from cavity 138. Cutter sidewall160 includes a recess 172 formed therein, and cutter sidewall 158includes a similarly shaped recess (not shown.)

Shaft 164 includes an interior channel 162 formed therethrough thatopens at the distal end of cutter 152. Channel 162 is sized to receivestem 116 and body portion 120 of distractor 118. This provides a slipfit between body portion 120 and cutting head 153 that will guidecutting head 153 into the disc space and into the bony material of theadjacent vertebral bodies. The sidewall recesses are sized and shaped toreceive body portion 120 of distractor 118 and allow cutting edges 154 aand 156 a to be advanced beyond the leading end 122 of distractor 118.End wall 146 prevents cutting head 153 from being advanced too farbeyond leading end 122.

Where a slot 142 is provided in distractor 118, a first guide pin 171and a second guide pin 173 are positioned in channel 162. Guide pins171, 173 extend between and are secured to upper member 154 and lowermember 156. Guide pins 171, 173 are slidingly received in guide slot142. Cutter 152 can be advanced over body portion 120 with body portion120 positioned in channel 162 and received in and extending laterallyoutwardly from sidewall recesses 172. Guide pins 171, 173 positioned inguide slot 142 prevent lateral deviation of cutting head 153 withrespect to body portion 120 as cutter 152 is advanced over distractor118. Pins 171, 173 further act as braces that stabilize and strengthenshaft 164 in the area of the sidewall recesses.

Distractor 118 has an overall width W1 between the first sidewall 126and second sidewall 128 that is greater the width W2 between thesidewalls 158, 160 of cutter 152. Guide slot 142 and pins 171, 173 andthe interfitted arrangement between distractor 118 and cutter 152 ensurethat the sidewalls of distractor 118 are positioned adjacent to theneural and vasculature tissue rather than the cutting edges of cutter152.

While the invention has been illustrated and described in detail in thedrawings and the foregoing description, the same is considered to beillustrative and not restrictive in character. It is understood thatonly the preferred embodiments have been shown and described and thatall changes and modifications that come within the spirit of theinvention are desired to be protected.

1. A method for preparing a spinal disc space, comprising: inserting abody portion of a distractor into the spinal disc space with an uppersurface of the body portion adjacent an endplate of an upper vertebraand a lower surface of the body portion adjacent an endplate of a lowervertebra, wherein the body portion includes at least one flangeextending from a distal end of the body portion towards a proximal endof the body portion; advancing a cutting instrument over the bodyportion between the at least one flange and the body portion to removematerial between at least one of the upper and lower surfaces of thebody portion and the adjacent vertebra; and depositing cut material intoa cavity formed in the body portion, the cavity opening toward at leastone of the upper and lower surfaces.
 2. The method of claim 1, whereinthe cavity opens at each of the upper and lower surfaces.
 3. The methodof claim 2, further comprising advancing the cutting instrument over thebody portion to remove material between the upper and lower surfaces ofthe body portion and each of the adjacent vertebra.
 4. The method ofclaim 3, further comprising depositing cut material into the cavitythrough each of the openings of the body portion.
 5. The method of claim1, wherein advancing the cutting instrument includes contacting thedistal end of the body portion to limit advancement of the cuttinginstrument into the disc space.
 6. The method of claim 1, whereininserting the body portion includes contacting the endplate of the upperand lower vertebrae with the adjacent one of the upper and lowersurfaces of the body portion.
 7. The method of claim 1, furthercomprising: removing the cutting instrument and the body portion fromthe disc space; and inserting an implant in the spinal disc space. 8.The method of claim 1, wherein the body portion includes a second flangeopposite the at least one flange, the second flange extending from thedistal end towards the proximal end of the body portion; and advancingthe cutting instrument includes advancing the cutting instrument overthe body portion between the body portion and each of the flanges. 9.The method of claim 1, wherein advancing the cutting instrument includesnavigating the cutting instrument with image guidance.
 10. A method forpreparing a spinal disc space, comprising: inserting a body portion of adistractor into the spinal disc space; advancing a cutting instrumentover the body portion into the spinal disc space; and limitingadvancement of the cutting instrument into the spinal disc space bycontacting the cutting instrument with a distal end wall of the bodyportion, wherein advancing the cutting instrument includes advancing thecutting instrument between a first flange and a second flange of thedistractor, each of the first and second flanges extending from a distalend of the body portion toward a proximal end of the body portion, eachof the first and second flanges forming a slot along the body portionfor receiving the cutting instrument.
 11. The method of claim 10,wherein: the distal end wall includes a first width; and the cuttinginstrument includes an elongated shaft having a distal cutting end, thedistal cutting end of the shaft configured to interfit with the bodyportion and includes a distally opening channel to receive the bodyportion of the distractor, the distal cutting end including a secondwidth that is less than the first width.
 12. The method of claim 10,further comprising depositing cut material into a cavity formed in thebody portion, the cavity opening toward at least one of upper and lowersurfaces of the body portion.
 13. The method of claim 10, furthercomprising: removing the cutting instrument and the body portion fromthe disc space; and inserting an implant in the spinal disc space. 14.The method of claim 10, wherein inserting the body portion includescontacting endplates of vertebrae adjacent the spinal disc space with anadjacent one of an upper surface and a lower surface of the bodyportion.
 15. A method for preparing a spinal disc space, comprising:inserting a body portion of a distractor into the spinal disc space;advancing a cutting instrument over the body portion into the spinaldisc space; and limiting advancement of the cutting instrument into thespinal disc space by contacting the cutting instrument with a distal endwall of the body portion, wherein advancing the cutting instrumentincludes advancing the cutting instrument between at least one flange ofthe distractor and the body portion of the distractor, the at least oneflange extending from a distal end of the body portion towards aproximal end of the body portion and forming a slot along the bodyportion for receiving the cutting instrument.
 16. The method of claim15, wherein: the distal end wall includes a first width; and the cuttinginstrument includes an elongated shaft having a distal cutting end, thedistal cutting end of the shaft configured to interfit with the bodyportion and includes a distally opening channel to receive the bodyportion of the distractor, the distal cutting end including a secondwidth that is less than the first width.
 17. The method of claim 15,wherein advancing the cutting instrument includes advancing the cuttinginstrument between a first flange and a second flange of the distractor,each of the first and second flanges extending from the distal end ofthe body portion toward the proximal end of the body portion, each ofthe first and second flanges forming a slot along the body portion forreceiving the cutting instrument.
 18. The method of claim 15, furthercomprising: removing the cutting instrument and the body portion fromthe disc space; and inserting an implant in the spinal disc space. 19.The method of claim 15, wherein inserting the body portion includescontacting endplates of vertebrae adjacent the spinal disc space with anadjacent one of an upper surface and a lower surface of the bodyportion.
 20. The method of claim 15, further comprising depositing cutmaterial into a cavity formed in the body portion, the cavity openingtoward at least one of upper and lower surfaces of the body portion.